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7-185-01 <br /> Please print or type.(Form designed for use on elite(12-pitc writer.) Form Approved.OMB No.2050-0039 <br /> UNIFORM HAZARDOUS 1 1.Generator ID Number 2.Page 1 of 3.Emergency Response Phone 4.faa Iffee((��7�TTr��r��JJckl���I�JJpp ry7�rn ' <br /> WASTE MANIFEST CAROOOS02707 {JLL 1 221 SKS <br /> 1 1—$04-468— 760 <br /> 5.Generators Name and Mailing Address ff r U(diRGr�Bt an mailing address) <br /> HOLZ RUBBER COMPANY INC. C�� <br /> 1129 S SACRAMENTO ST <br /> LODI CA 95240' <br /> Generatoes Phone: 800-2$5-1600 MAR 10 2010 <br /> 6.TraAj1r 1 Compan Name S.EPA ID Number <br /> SAFETY—KLEgN SYSTEMS, INC. BW TXR000050930 <br /> 7.Transporter 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and Site Address SAFETY—KLEEN SYSTEMS, INC. 000760 U.S.EPAIONumber <br /> 6000 88TH STREET <br /> 916-386-4913 <br /> SACRAMENTO CA 95828 / CA0000084517 <br /> r <br /> Facility's Phone: ,e <br /> 9a 96.U.S.DOT Desadption(including Proper Shipping Name,Hazard Class,ID Number, - 10.Containers 11.Total 12.Unci <br /> HM and Packing Group(8 any)) No. Type Quantity Wtivol. 13.Waste Codes <br /> X 1'dASTE PAINT RELATED MATERIAL.3, UN1263s DMP F003 D001 0018 <br /> PO III 36 <br /> 8035 0039 212 <br /> z 2. <br /> w <br /> t7 <br /> 3. <br /> 4. <br /> 4 <br /> 14.Special Handling ImItructions and Additional Information SK TRCKM111258321 0040757961$'Q003153217 1008 24 <br /> 1}ER01�128a� } r'�� ((''� <br /> 24 HR EMERGENCY M 8001468-1760(SAFETY-KLEEN{'— 94138) A <br /> jK AUTHORIZE TGRETAIM LICENSED SUBSEQUENT NECESSARY <br /> 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition fortransport according to applicable international and national governmental regulations.If export shipment and I am the Primary <br /> Exporter,I certify that the contents of this consignment conform to the terns of the attached EPA Acknowledgment of Consent. <br /> I certify that the waste minimization statement identified in 40 CFR 262.27(x)(if I am a large quantity generetw)or(b)(IN am a small quantity generator)is We. <br /> GeneratoesrOfierors Pnntedylyped,,,Name SignaNre Month Day Year <br /> 1021 /'01A) <br /> F '16.International Shipments fElim U.S. ❑Export from U.S. Art of entrylexil: <br /> Z Transporter sin Date leaving U.S.: <br /> at 17.Tmn rterftnowledgment of RBCBI of Materials <br /> h� Trans rteri PnnledRyped Name Signature Month Day Year <br /> Go Td T �� l <br /> QTranspoder 2 Printed/TypoeFffarne Signature Month Day Year <br /> K <br /> 18 Discrepancy <br /> i 18x.Discrepancy Indication Space ---_. _ -. _ _ <br /> ❑ Quantity LJ Type ❑Residue ❑Partial Rejection ❑Full Rejection <br /> f1 <br /> Manifest Reference Number: <br /> 181b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J <br /> V <br /> LL FadlBys Phone: <br /> Q 18c.Signature of Alternate Facility(or Generator) Month Day Year <br /> 2 <br /> N19.Hazardous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling systems) <br /> 1 N141 2. 3. 4, <br /> 20.Designated Facility Owner or Operator.Certification of receipt of hazardous materials covered by the manifest ex noted in Item 18a <br /> ped no ) Si Mwlth Day Year <br /> Go <br /> t)OP00,9100-22 <br /> 01 607(2j3-05) Previous Tiosam0bsolete. 4} DESIGNATED FACILITY TO GENERATOR <br />